PROJECT SUMMARY There are notable cardiovascular disease (CVD) disparities among people living in rural settings, particularly medically underserved rural areas. Complex factors such as socioeconomic disadvantage, social and cultural dynamics, geographic distances/barriers, and limited access to healthcare, healthy foods, and/or physical activity opportunities contribute to the issue. Montana is one of the most rural states, with 76% of its 998,199 people living in rural or frontier (<6 people/square mile) areas. Montana's CVD rates have declined similarly to U.S. rates, but it remains the leading cause of death, and CVD risk factors such as obesity, high cholesterol, hypertension, and diabetes are increasing. The objective of Strong Hearts, Healthy Communities (SHHC) is to reduce rural CVD disparities through civic engagement and implementation of a community-based intervention in 10 underserved Montana towns. SHHC builds upon a long-standing collaboration with National Institute of Food and Agriculture cooperative extension educators, who will implement the project. For Specific Aim 1, we will inform intervention development through community audits, qualitative research, and forming Community Advisory Boards (CABs) with residents, health educators, local leadership, and other stakeholders in the 10 towns. We will gather knowledge about economic, social/cultural, built environment, food access, healthcare, and related topics. For Aim 1.1, we will incorporate audit, focus group, and key informant findings as well as input from CABs to inform the SHHC curriculum, facilitate community engagement, and build capacity. For Aim 2, overweight and obese midlife and older women will participate in a 24-week community-randomized study. Subjects will attend twice weekly classes focused on exercise, nutrition, and CVD prevention education and skills. Each group will also choose a CVD-related community health issue of relevance to their town and help facilitate community events and activities, e.g. healthy foods, physical activity opportunitie, wellness services. We will evaluate anthropometric (e.g. BMI), physiologic (e.g. lipids, blood pressure), behavioral (e.g. 7-day accelerometry), and psychosocial (e.g. quality of life) outcomes. For Aim 2.1, we will evaluate attitudinal and behavioral changes among members of the SHHC participants' social network. Aim 2 intervention subjects will be asked to identify 1-5 of their closest friends and/or family members, who will be invited to complete baseline and follow-up questionnaires. The novel integration of community programming and civic engagement has the potential to effect clinically meaningful improvements in participants, families, and communities; this approach will help sustain reduced CVD rates by linking behavior change and community factors. Further, SHHC will provide a feasible model for other underserved rural communities to improve health and quality of life and reduce CVD risk among residents. In addition, we will convene a SHHC National Advisory Board, to provide expert guidance throughout the project, and to collaborate on a future large-scale effectiveness trial.